The Wall Street Journal reported on the care for extreme premature babies. The anecdote WSJ lead with was about a young woman whose water broke at the 22-week mark during her pregnancy. Methodist Hospital in suburban Minneapolis told her there was no chance her baby could survive. The expectant mother then quickly found Children’s Minnesota hospital. Children’s doctors acted quickly and saved her baby, who spent the next four months in the hospital. The baby is now four years old and meeting all the normal development milestones.
Here is the gist of the article: medical science can save premature babies earlier than ever. The practice is controversial and not all hospitals are equipped to save extreme premature babies, nor do all doctors think it’s wise to try.
Medical advances over the past several decades have given hospitals the ability to save younger and younger premature newborns. Yet most hospitals don’t try—and parents often aren’t aware of what’s possible or that other hospitals, even just a few miles away, might offer their newborns a fighting chance.Some U.S. hospitals aren’t sufficiently equipped or capable of pulling off the new advances. Others have chosen not to offer the care, saying it is likely to fail, is expensive—typically more than $100,000 a child, and sometimes much more—and subjects tiny, fragile infants to needless pain and the risk of long-term disabilities.
The $100,000 figure mentioned above strikes me as unrealistic. A more likely figure is neonatal bills of $1 million or more. In the WSJ anecdote, the baby spent four months in the hospital learning to breathe and a surgery to repair a hole in an artery near her heart. The result is a healthy happy four-year-old, but that’s not always the outcome. The issue is more nuanced than it sounds. Basically, the article is referring to a small subset of premature babies that are born on the edge of what is potentially futile and possibly ill-advised:
The difference can be a matter of life or death for the roughly 8,000 infants born between 22 and 24 weeks gestation in the U.S. each year.Doctors agree that babies born at 25 or 26 weeks can and should be treated as long as they don’t have other complications, while those born at 20 weeks or less are too small to save.
An expert on extremely premature babies stated the rate of progress has increased about one week every 10 years. Thus, during his four-decade career he can now save babies four weeks less developed than around 1980. Babies born at 22 weeks have a probability of survival of around 60%.
Still, saving a child born at 22 weeks is difficult. Their mouths and airways are small, making it difficult to intubate them. Their outer layer of skin is often only a few cells thick. Their guts are thin and can develop holes. They have trouble regulating their body temperature and often fall prey to hypothermia. They usually need months of treatment.
How early is too early? Sometimes surviving long enough to leave the hospital is not the end of the story.
In a group of more than 10,000 babies born between 2013 and 2018 at 19 U.S. academic medical centers, about 30% of those infants offered medical treatment at 22 weeks survived long enough to go home from the hospital, according to a 2022 study in the journal JAMA.Roughly half of 29 of those children who were evaluated at two years of age had severe or moderate neurodevelopmental disabilities, while the other half had no or mild disabilities.
There is undoubtedly selection bias in the sample mentioned in the paragraph above. The 29 children brought in at age two were likely brought in to assess developmental problems. That could mean the probability of developmental problems is 1% (29/3,000). Or it could mean many of the other 2,981 did not seek evaluation for developmental problems but still had some. One neonatologist, with 30 years experience, told WSJ the data does not support offering care at 22 weeks due to developmental problems, causing many to never be able to live independently.